A Calcificação do Arco Aórtico Observada na Radiografia de Tórax Pode Servir Como um Preditor Independente de Acidente Vascular Cerebral Recorrente / Aortic Arch Calcification Observed on Chest X-Ray May Serve as an Independent Predictor for Recurrent Stroke

Resumo Fundamento Apesar dos avanços nas modalidades de diagnóstico e tratamento, há necessidade de marcadores preditivos para acidente vascular cerebral (AVC) recorrentes. Objetivos Este estudo teve como objetivo investigar a relação entre calcificação do arco aórtico (CAA) e recorrência de AVC em pacientes com AVC durante o acompanhamento de um ano. Métodos Todos os pacientes com AVC que sofreram seu primeiro evento foram avaliados para participação no estudo. Foram registrados pacientes que sofreram AVC recorrentes durante o acompanhamento de um ano. A CAA foi avaliada por radiografia de tórax. Com base na ocorrência de AVC recorrente, os pacientes foram divididos em dois grupos. A CAA foi classificada em quatro categorias de acordo com o seu grau, e a presença de CAA foi incluída na análise estatística. A relação entre CAA e AVC recorrente foi avaliada por meio de uma curva característica de operação do receptor. Um nível de significância <0,05 foi considerado aceitável para todas as análises estatísticas. Resultados Um total de 203 pacientes foram incluídos no estudo (46,8% mulheres, média de idade 69±12,3). AVC recorrente foi detectado em 49 pacientes. CAA, hipertensão e fibrilação atrial foram mais frequentes em pacientes com AVC recorrente. Pacientes com AVC recorrente apresentaram menor taxa de filtração glomerular e maior largura de distribuição de glóbulos vermelhos (RDW). Na análise de regressão multivariada, CAA (hazard ratio [HR], 3,544; IC 95%:1,653-7,598, p=0,001) e RDW (HR,1,214; IC 95%:1,053-1,400, p=0,008) foram identificados como preditores independentes de AVC recorrente. Conclusão A presença de CAA (≥ grau 1) e RDW foram significativamente associadas ao desenvolvimento de AVC recorrente dentro de um ano. Esses achados podem ter significado prognóstico no acompanhamento de pacientes com AVC.

Abstract Background Despite advances in diagnostic and treatment modalities, there is a need for predictive markers for recurrent strokes. Objectives This study aimed to investigate the relationship between aortic arch calcification (AAC) and stroke recurrence in stroke patients during a one-year follow-up. Methods All stroke patients who experienced their first event were evaluated for participation in the study. Patients who experienced recurrent strokes during the one-year follow-up were recorded. AAC was assessed by chest radiography. Based on the occurrence of recurrent strokes the patients were divided into two groups. AAC was classified into four categories according to its degree, and the presence of AAC was included in the statistical analysis. The relationship between AAC and recurrent stroke was assessed using a receiver operating characteristic curve. A significance level of <0.05 was deemed acceptable for all statistical analyses. Results A total of 203 patients were included in the study (46.8% female, mean age 69±12.3). Recurrent stroke was detected in 49 patients. AAC, hypertension, and atrial fibrillation were more frequent in patients with recurrent stroke. Patients with recurrent stroke had a lower glomerular filtration rate and a higher red cell distribution width (RDW). In multivariate regression analysis, AAC (hazard ratio [HR], 3.544; 95% CI:1.653-7.598, p=0.001) and RDW (HR,1.214; 95% CI:1.053-1.400, p=0.008) were identified as independent predictors of recurrent stroke. Conclusion The presence of AAC (≥ grade 1) and RDW were found to be significantly associated with the development of recurrent stroke within one year. These findings may have prognostic significance in the follow-up of stroke patients.

Is Deep Hypothermic Cardiac Arrest Mandatory in Aortic Arch Surgeries?

ABSTRACT Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Application of Computed Tomography Angiography in Preoperative Diagnosis of Coarctation of Aorta and Evaluation of Aortic Dilatation in Infants

ABSTRACT Objective: To evaluate the occurrence of aortic dilatation and its associated predictors with coarctation of the aorta (CoA) in infants using multi-slice computed tomography (MSCT). Methods: The clinical data of 47 infantile patients with CoA diagnosed by MSCT and 28 infantile patients with simple ventricular septal defect were analyzed retrospectively. Aortic diameters were measured at six different levels, and aortic sizes were compared by z score. The coarctation site-diaphragm ratio was used to describe the degree of narrowing. Relevant clinical data were collated and analyzed. Results: The dilation rate and z score of the ascending aorta in the severe CoA group were significantly higher than those in the mild CoA group (11 [52.38%] vs. 21 [80.77%], P=0.038 and 2.00 ± 0.48 vs. 2.36 ± 0.43, P=0.010). Pearson's correlation analysis found that the z score of the ascending aorta was negatively correlated with the coarctation site-diaphragm ratio value (r=-0.410, P=0.004). A logistic retrospective analysis found that an increased degree of coarctation was an independent predictor of aortic dilatation (adjusted odds ratio 0.002; 95% confidence interval 0.00-0.819; P=0.043). The z score of the ascending aorta in the severe CoA group was significantly higher than that in the ventricular septal defect group (P<0.05). Conclusion: Most infants with CoA can also have significant dilatation of the ascending aorta, and the degree of this dilatation is related to the degree of coarctation. Assessment of aortic diameter and related malformations by MSCT can predict the risk of aortic dilatation in infants with CoA.

Type A Aortic Dissection Following Heart Transplantation

ABSTRACT Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Disección de aorta secundario a trauma, manejo clínico en Hospital General / Aortic dissection secondary to trauma, clinical management in General Hospital

INTRODUCCIÓN. La disección de aorta es una patología poco frecuente, cuando se presenta, lo hace de una manera catastrófica manifestada por dolor torácico o lumbar intenso acompañado de compromiso hemodinámico agudo, un diagnóstico y tratamiento temprano suelen ser cruciales para evitar la muerte del paciente, así mismo, una disección de aorta puede ser secundario a un trauma torácico por desaceleración y se presenta en 1,5% a 2%, lo que induce sobre todo a un desgarro localizado en la región del istmo aórtico. CASO CLÍNICO. Paciente masculino de 35 años, con antecedente de accidente en vehículo motorizado que provocó un traumatismo cráneo encefálico moderado, hematoma epidural parietal derecho, con resolución quirúrgica hace 18 meses, se descartó lesiones a nivel de tórax con radiografía de tórax normal, además se realizó ecografía FAST en ventana perihepática, suprapúbica, periesplénica y subxi-foidea sin encontrar alteración. Acudió al servicio de emergencia por un cuadro de hemiparesia derecha más disartria de 4 horas de evolución, se realiza tomografía de cráneo sin encontrarse lesión, catalogándose como evento cerebrovascular isquémico con recuperación neurológica. Durante su estancia hospitalaria presenta un cuadro de disnea de grandes esfuerzos y tras realizar exámenes complementarios de control se llega a una conclusión de una cardiomegalia, por lo que es referido a consulta de cardiología donde se realiza ecocardiograma, en la cual se observa disección de aorta ascendente más aneurisma por lo que se decide su ingreso y se instaura tratamiento mediante medidas de soporte, con derivación a hospital de especialidades para cirugía cardiotorácica. CONCLUSIONES. La disección de aorta secundario a un traumatis-mo es poco frecuente, sin embargo, el diagnostico siempre debe estar presente en caso de trauma por desaceleración, ya que es vital para la supervivencia del paciente y su manejo oportuno.

INTRODUCTION. Aortic dissection is an infrequent pathology; when it occurs, it does so in a catastrophic manner manifested by intense thoracic or lumbar pain accompanied by acute he-modynamic compromise. Early diagnosis and treatment are usually crucial to avoid the patient's death; likewise, aortic dissection can be secondary to thoracic trauma due to deceleration and occurs in 1.5% to 2%, which mainly induces a localized tear in the region of the aortic isthmus. CLINICAL CASE. 35-year-old male patient, with a history of motor vehicle accident that caused a moderate head injury, right parietal epidural hematoma, with surgical resolution 18 months ago, chest injuries were ruled out with normal chest X-ray, and FAST ultrasound was performed in perihepatic, suprapubic, perisplenic and subxiphoid window without finding any alteration. She went to the emergency department for a picture of right hemiparesis and dysarthria of 4 hours of evolution, a cranial tomography was performed without finding any lesion, being clas-sified as an ischemic cerebrovascular event with neurological recovery. During his hospital stay he presented with dyspnea of great effort and after performing complementary control tests, a cardiomegaly was found, so he is referred to a cardiology clinic where an echocardiogram is per-formed, which showed dissection of the ascending aorta plus aneurysm, admission is decided and treatment is instituted through supportive measures, with referral to a specialty hospital for cardiothoracic surgery. CONCLUSIONS. Aortic dissection secondary to trauma is rare, however, the diagnosis should always be present in case of trauma due to deceleration, as it is vital for the survival of the patient and its timely treatment.

Fate of the Patent False Lumen of the Descending Aorta After Surgical Treatment for Acute Type 1 Aortic Dissection

ABSTRACT Introduction: This study aimed to investigate the factors affecting false lumen patency in the descending thoracic aorta among patients who underwent surgery for acute type 1 aortic dissection. Methods: A total of 112 patients with acute type 1 aortic dissection, with the flap below the diaphragm level, underwent surgery between January 2010 and September 2019. Of these, 60 patients who were followed up for ≥ 12 months and whose computed tomography scans were available were included in this study. The patients were divided into two groups: group I, consists of patent false lumen (n=36), and group II, consists of thrombosed false lumen (n=24). Demographic data, operative techniques, postoperative descending aortic diameters, reintervention, and late mortality were compared between the two groups. Results: The mean follow-up period of all patients was 37.6±26.1 months (range: 12-104). The diameter increase in the proximal and distal descending aorta was significantly higher in the patent false lumen group (5.3±3.7 mm vs. 3.25±2.34 mm; P=0.015; 3.1±2.52 mm vs. 1.9±1.55 mm; P=0.038, respectively). No significant difference in terms of hypertension was found between the two groups during the follow-up period (21 patients, 58.3% vs. 8 patients, 33.3%; P=0.058). A total of 29 patients (48.3%) were found to be hypertensive in the postoperative period. Conclusion: After surgical treatment for acute type 1 aortic dissection, patients should be monitored closely, regardless of whether the false lumen is patent or thrombosed. Mortality and reintervention can be seen in patients with patent false lumen during follow-up.

Tratamiento endovascular con técnica de chimenea para patologías del arco aórtico / Endovascular management with chimney technique for pathologies ofthe aortic arch

Introducción. La patología del arco aórtico se ha tratado principalmente con cirugía por vía abierta, pero con una alta morbimortalidad. Las técnicas endovasculares híbridas y las reconstrucciones en "chimenea" son una técnica válida y segura para disminuir el riesgo y la mortalidad. Métodos. Se presentan dos pacientes con patología del arco aórtico y contraindicación de manejo quirúrgico abierto, atendidos en el Servicio de Cirugía Vascular, Hospital Universitario Clínica de San Rafael, Bogotá, D.C., Colombia. Resultados. Se realizaron dos procedimientos endovasculares del arco aórtico para tratar un aneurisma torácico roto y una úlcera aórtica sintomática, con cubrimiento de los troncos supra aórticos con una endoprótesis y canalización de los vasos supra aórticos con prótesis cubiertas y uso de la "técnica de chimenea", de manera exitosa. Discusión. La patología del arco aórtico es de alta complejidad y se asocia con una morbimortalidad elevada por lo que, en los últimos 20 años se han desarrollado diferentes técnicas utilizando procedimientos percutáneos. Conclusión. La "técnica de chimenea" se puede realizar de una manera mínimamente invasiva en pacientes con patología del arco aórtico, no candidatos para cirugía abierta, con resultados exitosos.

Introduction. Aortic arch pathology has been treated mainly by open surgery, but with high morbidity and mortality. Hybrid endovascular techniques and "chimney" reconstructions are a valid and safe techniques to reduce risk and mortality. Method. Two patients with pathology of the aortic arch and contraindication for open surgical management, treated at the Vascular Surgery Service, Hospital Universitario Clínica de San Rafael, Bogotá, Colombia, are presented. Results. Two endovascular aortic procedures were performed successfully to treat a ruptured thoracic aneurysm and a symptomatic aortic ulcer, with coverage of the supra-aortic trunks with an endoprosthesis and cannulation of the supra-aortic vessels with covered prostheses and use of the "chimney technique". Discussion. The pathology of the aortic arch is highly complex and is associated with high morbidity and mortality, being the reason that during the last 20 years, different techniques have been developed using percutaneous procedures. Conclusions. The "chimney technique" can be performed with successful results in a minimally invasive manner in patients with pathology of the aortic arch, who are not candidates for open surgery

Two Cases of Secondary Hypertension with Rare Aetiology

Secondary Hypertension comprises approximately 5% of Systemic Hypertension1. Renal parenchymal, Renovascular and Endocrine Diseases are amongst the common causes of Secondary Hypertension. Takayasu,s Arteritis is a rare form of Primary Systemic Vasculitis that appears to be commoner in Asia than Europe or North America2 and in contrast to Japanese patients, who have a higher incidence of aortic arch involvement, the series from India reports higher incidences of thoracic and abdominal involvement. In general, patients from Indian subcontinent tend to have greater prevalence of Pan-aortic Disease (both above and below the diaphragm) when compared with the west. In India the women : men ratio is around 1.5:1. Takayasu, s Arteritis most frequently affects young women3. Therapeutic intervention like Percutaneous Transluminal Angioplasty (PTA) and Stenting, By-pass Surgeries or surgical reconstruction should be performed when disease is made inactive by the use of effective immunosuppressive Therapy4

Coarctation of the aorta in a young female treated with left subclavian artery to descending thoracic aorta bypass: a case report / Coarctação de aorta em jovem tratada com artéria subclávia esquerda para bypass de aorta torácica descendente: relato de caso

Abstract Coarctation of the aorta is a rare congenital abnormality, with an incidence of 6-8% of all congenital heart problems. It is usually diagnosed in childhood during routine clinical examination and adults mostly present with hypertension. Various investigations like transthoracic echocardiography, computed tomography, and magnetic resonance angiography can help with diagnosis. Prognosis depends on age at presentation and the severity of coarctation. Treatment options available are open and endovascular repair. Extra-anatomical bypass is the preferred option in cases with unfavorable anatomy. Long term follow up is required post repair due to risk of restenosis and aneurysm formation. Here is a case in which a young female presented with hypertension, was diagnosed with coarctation of the aorta, and was treated a left subclavian artery to descending thoracic aorta bypass. Her postoperative course was uneventful and she had improvement in hypertension.

Resumo A coarctação da aorta é uma anomalia congênita rara, com incidência de 6-8% entre todos os problemas cardíacos congênitos. É geralmente diagnosticada na infância durante o exame clínico de rotina, e os adultos normalmente apresentam hipertensão. Diversas investigações, como ecocardiografia transtorácica, tomografia computadorizada e angiorressonância magnética, podem auxiliar no diagnóstico. O prognóstico depende da idade na apresentação e da gravidade da coarctação. As opções de tratamento disponíveis são o reparo aberto e o reparo endovascular. O bypass extra-anatômico é a opção preferida em caso de anatomia desfavorável. O acompanhamento de longo prazo é necessário após o reparo devido ao risco de reestenose e formação de aneurisma. Descrevemos o caso de uma jovem do sexo feminino que apresentou hipertensão, a qual foi diagnosticada como coarctação da aorta. Foi realizada derivação da artéria subclávia esquerda para a aorta torácica descendente. O pós-operatório transcorreu sem intercorrências, e a paciente apresentou melhora da hipertensão.

Reparación endovascular de la aorta torácica, resultados a largo plazo / Endovascular repair of the thoracic aorta, long-term results

Resumen Introducción: Las diversas patologías de la aorta torácica descendente, representan una implícita amenaza para la vida, y son potencialmente tratables mediante reparación endovascular. Objetivo: Evaluar los resultados de la reparación endovascular de la aorta torácia descendente (TEVAR). Material y Método: Estudio observacional, retrospectivo y descriptivo, donde se analiza TEVAR, en un período de 10 años (2009 al 2019), en el Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Se realizó TEVAR en 31 pacientes, sexo masculino 74,2%, femenino 25,8%, edad promedio 67,8 años (rango 53-85), patologías asociadas: hipertensión arterial sistémica (77,4%), tabaquismo (67,7%) y dislipidemia (38,7%), las indicaciones para TEVAR fueron: el aneurisma de la aorta descendente (51,61%), la disección tipo B crónica complicada (29,03%), y la disección tipo B aguda complicada (19,35%), relacionado al procedimiento se evidenció: morbilidad cardiovascular (12,9%) y morbilidad neurológica (6,45%), complicaciones relacionadas a la endoprótesis (29,03%), incidencia de endofugas (19,35%), estancia hospitalaria promedio de 5,2 días (rango 3 a 17), seguimiento promedio de 47,3 meses (9-108), éxito técnico primario (100%), tasa de reintervención: 3,22%, tasa de supervivencia a 1, 3, 5 años del 96,77%, 93,54 y 90,32% respectivamente, no hubo mortalidad menor a 30 días. Discusión: La evidencia demuestra que TEVAR puede realizarse en forma segura y efectiva, cumpliendo estrictos criterios clínicos y condiciones anatómicas, representando la modalidad de elección para la reparación de las lesiones de la aorta descendente. Conclusión: Los resultados demuestran que TEVAR, representa una excelente estrategia terapeutica, menos invasiva, con baja morbilidad y mortalidad asociada.

Introduction: The pathological injuries of the descending thoracic aorta, represent an implicit threat to life, and are potentially treatable by endovascular repair. Aim: To evaluate the results of endovascular repair of the descending thoracic aorta (TEVAR) in the medium and long term. Material and Method: Observational, retrospective and descriptive study, where TEVAR is analyzed, over a period of 10 years (2009 to 2019), at the Dr. Eduardo Pereira Hospital in Valparaíso, Chile. Results: TEVAR was performed in 31 patients, male sex 74.2%, average age 67.8 years (range 53-85), symptomatic 64.5%, associated pathologies: systemic arterial hypertension (77.4%), smoking (67.7%) and dyslipidemia (38.7%), indications for endovascular repair were descending aortic aneurysm (51.61%), complicated Stanford type B chronic aortic dissection (29.03%), and complicated Stanford type B acute aortic dissection (19.35%), neurological morbidity (6.45%), cardiovascular morbidity (12.9%), complications related to the stent (29.03%), where endoleaks predominate (19.35%), average hospital stay of 5.2 days (range 3 to 17), average followup of 47.3 months (9-108), primary technical success (100%), survival rate at 1, 3, 5 years of 96.77%, 93.54 and 90.32% respectively, there was no mortality less than 30 days or reoperation. Discussion: the evidence shows that TEVAR can be performed safely and effectively, meeting strict clinical criteria and anatomical conditions, which represents the modality of choice for the repair of lesions in the descending aorta. Conclusion: The results show that TEVAR represents an excellent therapeutic strategy, less invasive, with low associated morbidity and mortality.

Prevalencia de dilatación aórtica en pacientes con válvula aórtica bicúspide según los valores de referencia de la población argentina / Prevalence of Aortic Dilation in Patients with Bicuspid Aortic Valve According to Reference Values for the Argentine Population

RESUMEN Introducción: Una proporción significativa de los pacientes con válvula aórtica bicúspide (VAB) desarrollan una dilatación de la aorta que los predispone a serias complicaciones. Objetivos: Estimar la prevalencia de dilatación aórtica aplicando los valores de referencia de la población argentina en pacientes con VAB y la influencia de los distintos métodos de indexación (talla, T, y superficie corporal, SC). Materiales y métodos: Se incluyeron consecutivamente 581 pacientes adultos con VAB. Se definió la dilatación según el criterio propuesto por las guías (fórmulas de Devereux) y sobre la base de los valores propuestos por el registro MATEAR (Medición de Aorta Torácica por Ecocardiografía en Argentina). Resultados: La edad media fue de 44,9 años (±16), 68,7% sexo masculino. Sobre la base del registro MATEAR se observó alta prevalencia de dilatación de la raíz aórtica o aorta ascendente (72,3% según T y 61,5% según SC) que resultó, en la raíz, mayor que la obtenida según las fórmulas de Devereux (T 47% vs. 31,5%; SC 35,2% vs. 26,5% p < 0,001). Se observó una subestimación sistemática al indexar por SC en pacientes con índice de masa corporal >25 kg/m² (57,8% de la población). Conclusiones: La prevalencia de dilatación aórtica, cuando aplicamos los valores de referencia para la población argentina, fue alta y en la raiz significativamente mayor que la determinada por puntos de corte originados en otras poblaciones. Se observó una subestimación sistemática al corregir por superficie corporal en pacientes con índice de masa corporal >25 kg/m², por lo que indexar por talla sería la opción más recomendable.

ABSTRACT Background: A significant proportion of patients with bicuspid aortic valve (BAV) develop aortic dilation predisposing to serious complications. Objective: The aim of this study was to estimate the prevalence of aortic dilation applying reference values for the Argentine population in patients with BAV, and the influence of different indexing methods [height, (H) and body surface area (BSA)] Methods: A total of 581 adult patients with BAV were consecutively included in the study. Aortic dilation was defined according to guideline criteria (Devereux formula) and the reference values suggested by the Echocardiography Thoracic Aortic Assessment in Argentina (MATEAR) registry. Results: Mean age was 44.9±16 years and 68.7% were men. A high prevalence of aortic root or ascending aorta dilation was observed based on MATEAR criteria (72.3% according to H and 61.5 % according to BSA). This was significantly higher for the aortic root than the one obtained with the Devereux formula (H: 47% vs. 31.5%; BSA: 35.2% vs. 26.5% P <0.001). A systematic underestimation was found when indexing for BSA in patients with body mass index (BMI) >25 kg/m² (57.8% of population). Conclusions: When applying the reference values for the Argentine population the prevalence of aortic dilation was high and significantly greater than at the root that determined by cutoff points originating in other populations. Systematic underestimation was observed when correcting for BSA in patients with BMI >25 kg/m², so indexing by H would be the most recommended option.

Damage control surgery for thoracic outlet vascular injuries: the new resuscitative median sternotomy plus REBOA / Cirugía de control de daños para lesiones del opérculo torácico: nuevo abordaje mediante esternotomía mediana y REBOA

Abstract Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. This article aims to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with a zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated, followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.

Resumen El trauma vascular torácico está asociado con una alta mortalidad y es la segunda causa más común de muerte en pacientes con trauma después del trauma craneoencefálico. Se estima que menos del 25% de los pacientes con una lesión vascular torácica alcanzan a llegar con vida para recibir atención hospitalaria y más del 50% fallecen en las primeras 24 horas. El trauma torácico penetrante con compromiso de los grandes vasos es un problema quirúrgico dado a su severidad y la asociación con lesiones a órganos adyacentes. El objetivo de este artículo es presentar la experiencia en el manejo quirúrgico de las lesiones del opérculo torácico con la creación de un algoritmo de manejo quirúrgico en seis pasos prácticos de seguir basados en la clasificación de la AAST. que incluye los principios básicos del control de daños. La esternotomía mediana de resucitación junto con la colocación de un balón de resucitación de oclusión aortica (Resuscitative Endovascular Balloon Occlusion of the Aorta - REBOA) en zona 1 permiten un control primario de la hemorragia y mejoran la sobrevida de los pacientes con trauma del opérculo torácico e inestabilidad hemodinámica.

Vasodilating effect of suberoylanilide hydroxamic acid on isolated thoracic aorta of rats and its mechanisms / 中国药理学通报

Aim To investigate the vasodilating effect of suberoylanilide hydroxamic acid ( SAHA) on isolated thoracic aorta of rats and the possible mechanisms. Methods Isolated thoracic aorta of rats were used to perfuse, and to observe the effect of accumulated concentration of SAHA (0.3, 1, 3, 10 and 30 p,mol • L_1) on isolated thoracic aorta at basal state, KC1 and NE precontracted state. At the same time, L-NAME, Indo, PMA and SP were used to explore its possible mechanisms of relaxing isolated thoracic aorta, and to investigate the role of the Ca2 during the vasodilating process. Results SAHA could relax KC1 and NE precontracted isolated thoracic aorta of rats (P <0. 01), and the effect on endothelium-intact was stronger than that on endothelium-denuded thoracic aorta (P < 0.01), but there was no significant effect on thoracic aorta at basal state. The vasodilatory effect of SAHA could be inhibited by L-NAME, Indo and PMA (P < 0.05), while that could be promoted by SP ( P < 0. 01). SAHA could attenuate vasoconstriction induced by CaCl2 and NE through inhibiting extracellular Ca2 + influxe and intracellular Ca2 release in a concentration-dependent manner ( P < 0. 01). Conclusions The vasodilating mechanisms of SAHA may be related to the increased production of vasodilatory factors NO and PGt2, and the inhibition of PKC, and the inhibition of extracellular Ca2 + influxe and intracellular Ca2 + release.

Hyperoside ameliorates the injury of heart and thoracic aorta in mice with myocardial infarction by regulating autophagy pathway / 中国临床药理学与治疗学

AIM: To explore the protection of Hyperoside (Hyp) on heart and thoracic aorta in mice with myocardial infarction (MI) as well as its potential mechanism. METHODS: The MI model was generated by a ligation on the left anterior descending coronary artery. The mice were then randomly divided into sham group (saline, 0.1 mg/10 g), model group (saline, 0.1 mg/10 g), Hyp-low, moderate and high concentration groups (Hyp, 9, 18 and 36 mg/kg), Fosinopril group (Fosinopril, 15 mg/kg), and Hyp-high concentration + 3-MA group (Hyp, 36 mg/kg; 3-MA, 30 mg/kg). The mice were treated with Hyp and Fosinopril for two weeks, and then the changes of heart weight versus body weight (HW/BW), electrocardiogram (ECG) remodeling, cardiac function, oxidative stress level in serum, thoracic aorta remodeling and endothelial function were investigated. RESULTS: In the model group, the HW/BW was elevated (P<0.01). The width of QRS in ECG was elevated, as a company with the reduction of height of QRS (P<0.01). The echocardiography assay showed that the cardiac cavity was enlarged (P<0.01). The oxidative stress level in serum was enhanced (P<0.01). The thoracic aorta remodeling and endothelial dysfunction became more serious (P<0.01). After being treated with different concentrations of Hyp and fosinopril for two weeks, the changes above were reserved (P<0.05, P<0.01). Co-treatment with 3-MA, an autophagy inhibitor, suppressed the protective effects of Hyp on impaired hearts and vessels (P<0.05, P<0.01). CONCLUSION: Hyp has protective prospects on injured heart and thoracic aorta remodeling, as well as endothelial dysfunction in MI mice; 3-MA, an autophagy inhibitor, can reverse the cardiovascular protection of Hyp. The mechanism may be explained that Hyp can elevate autophagy level in heart, which further weaken oxidative injury in MI mice.

Calcificações na aorta torácica e nas artérias coronárias: associações com os fatores de risco cardiovascular em participantes do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) em Minas Gerais / Calcificações na aorta torácica e nas artérias coronárias: associações com os fatores de risco cardiovascular em participantes do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) em Minas Gerais

As calcificações na aorta torácica (TAC) e nas artérias coronárias (CAC) estão associadas com risco de doença cardiovascular (DCV) e morte. Entretanto, os fatores de risco associados às calcificações arteriais podem variar de acordo com o leito vascular. Verificamos se TAC estão associadas aos mesmos fatores de risco que CAC em adultos sem DCV estabelecida e, em seguida, averiguamos se existiam diferenças entre as associações dos fatores de risco para DCV com cada segmento da aorta torácica (porções ascendente, arco e descendente). Trata-se de estudo transversal, incluindo 2.433 participantes (entre 38 e 78 anos de idade) da coorte do ELSA-Brasil em Minas Gerais. Foram realizados exames de tomografia computadorizada multislice sincronizada com ECG para identificar cálcio na aorta torácica e nas coronárias (2015-2016). As associações tanto de CAC quanto de TAC, total e por segmentos, com os fatores de risco para DCV (tabagismo, índice de massa corporal [IMC], atividade física, uso excessivo de álcool, história familiar de DCV, LDL, HDL, HbA1c, níveis de pressão arterial, uso de medicamentos para hipertensão arterial, diabetes e hipolipemiantes) foram avaliadas através de regressão logística multivariada. A prevalência total de TAC e CAC foi de 69% e de 43%, respectivamente. A prevalência de CAC foi menor entre as mulheres (31%) do que entre os homens (56%). Após ajustes, negros apresentaram menor probabilidade de ter qualquer CAC comparado aos brancos. Nem sexo nem raça apresentaram associação significativa com TAC. O uso de medicamentos antidiabéticos permaneceu associado ao CAC, mas não ao TAC. Em relação ao estudo das associações entre os fatores de risco e cada segmento da aorta torácica, a prevalência das calcificações foi maior no arco (62%), seguido pelas porções descendente (31%) e ascendente (23%). Apesar da distribuição das calcificações ao longo da aorta ter sido heterogênea, não foram observadas diferenças importantes entre as associações dos fatores de risco com cada segmento aórtico. Em nenhum segmento houve diferença estatisticamente significativa na prevalência das calcificações em homens e mulheres, ou entre a cor da pele/raça. O aumento da idade, os menores níveis de escolaridade, tabagismo, hipertensão arterial e IMC permaneceram associados a presença de cálcio em todos os segmentos estudados. Em conclusão, CAC e TAC apresentaram diferenças entre as associações com os fatores de risco, principalmente em relação ao sexo e a raça. Entretanto, a distribuição heterogênea das calcificações ao longo da aorta não determinou diferenças significativas entre as associações dos fatores de risco com cada segmento da aorta torácica.

Thoracic aortic calcium (TAC) and coronary artery calcium (CAC) are associated with an increased risk of cardiovascular disease (CVD) and death. However, risk factors associated with arterial calcium may vary across vascular beds. We verified whether TAC is associated with the cardiovascular (CV) risk factors as is CAC in adults without established CVD, and compared the associations between the same risk factors to each segment of thoracic aorta (ascending, aortic arch, and descending portions). Cross-sectional analysis including 2,433 participants (aged 38 to 78 years) of ELSA-Brasil cohort in Minas Gerais. Nonenhanced ECG-gated multislice computed tomography were performed to detect calcium in the thoracic aorta and in the coronaries (2015 to 2016). Multivariate logistic regression evaluated the associations of both TAC, total and by segment, and CAC with CV risk factors (smoking, body mass index [BMI], physical activity, alcohol intake, family history of CVD, low-density lipoprotein- and high-density lipoprotein-cholesterol, HbA1c, blood pressure, antidiabetic, antihypertensive, and lipid lowering medications). Overall prevalence of TAC and CAC were 69% and 43%, respectively. CAC prevalence was lower among women (31%) than men (56%). After adjustments, black individuals were less likely to have any CAC as compared with whites. Neither sex, nor race/skin color were statistically associated with TAC. Use of antidiabetic medications remained associated with CAC, but not with TAC. Regarding to aortic segments, the higher prevalence of calcium was in the aortic arch (62%), followed by the descending (31%), and ascending portions (23%). Although the calcium distribution along the aorta is very heterogeneous, there were small differences between the associations of risk factors and each segment of thoracic aorta. There were no significant differences related to gender and race/skin color in any studied segment. Increasing age, lower scholarities levels, smoking, arterial hypertension, and higher BMI remained associated with calcium in all segments. In conclusion, CAC and TAC had differences in the associations with risk factors, mainly related to gender and race/skin color. Moreover, the heterogeneous distribution of calcium along the aorta did not affected the associations between the cardiovascular risk factors and each segment, since the associations shared many similarities among the aortic segments.

Aortic Arch Calcification on Routine Chest Radiography is Strongly and Independently Associated with Non-Dipper Blood Pressure Pattern / A Calcificação no Arco Aórtico na Radiografia de Tórax de Rotina está Forte e Independentemente Associada ao Padrão Não-Dipper de Pressão Arterial

Abstract Background: Non-dipper blood pressure (NDBP) is one of the important causes of hypertension-related target organ damage and future cardiovascular events. Currently, there is no practical tool to predict NDBP pattern. Objectives: The aim of this study was to investigate the relationship between aortic arch calcification (AAC) on chest radiography and NDBP pattern. Methods: All patients referred for ambulatory BP monitoring test were approached for the study participation. NDBP was defined as the reduction of ≤10% in nighttime systolic BP as compared to the daytime values. AAC was evaluated with chest radiography and inter-observer agreement was analyzed by using kappa statistics. Univariate and multivariate logistic regression analysis was conducted to assess the association of AAC and NDBP pattern. A 2-tailed p-value < 0.05 was considered statistically significant. Results: A total of 406 patients (median age: 51.3) were included. Of these, 261(64%) had NDBP pattern. Overall, the prevalence of AAC was 230 (57%). Non-dipper group had significantly higher prevalence of AAC (70% vs. 33%, p < 0.0001) as compared to the dipper group. Presence of AAC was a strong and independent predictor of NDBP pattern (OR 3.919, 95%CI 2.39 to 6.42) in multivariate analysis. Conclusions: Presence of AAC on plain chest radiography is strongly and independently associated with the presence of NDBP pattern.

Resumo Fundamento: A pressão arterial não-dipper é uma das causas mais importantes de lesão de órgão-alvo da hipertensão e de eventos cardiovasculares futuros. Atualmente, não há uma ferramenta prática para prever o padrão não-dipper de pressão arterial. Objetivos: O objetivo deste estudo foi investigar a relação entre a calcificação no arco aórtico detectada no raio de tórax e o padrão não-dipper de pressão arterial. Métodos: Todos os pacientes encaminhados para monitorização ambulatorial da pressão arterial foram abordados para participação no estudo. A pressão arterial não-dipper foi definida como a redução de ≤10% da pressão arterial sistólica noturna quando comparada com os valores diários. A calcificação no arco aórtico foi avaliada através de radiografia do tórax e a concordância interobservador foi analisada utilizando a estatística kappa. Análises de regressão logística uni e multivariada foram realizadas para avaliar a associação entre a calcificação no AA e o padrão PADV. Valores de p bicaudais < 0,05 foram considerados estatisticamente significativos. Resultados: Ao todo, 406 pacientes (idade mediana: 51,3) foram incluídos. Desses, 261(64%) apresentavam padrão não-dipper de pressão arterial. De modo geral, a prevalência de calcificação no arco aórtico foi de 230 (57%). O grupo não-dipper apresentou prevalência significativamente maior de calcificação no arco aórtico (70% vs. 33%, p < 0,0001) em relação ao grupo dipper. A presença de calcificação no arco aórtico foi um preditor forte e independente de padrão não-dipper de pressão arterial (OR = 3,919; IC: 95% 2,39-6,42) em análise multivariada. Conclusões: A presença de calcificação no arco aórtico em raio-x de tórax simples está forte e independentemente associada à presença de padrão não-dipper de pressão arterial.

Effect of chronic intermittent hypobaric hypoxia on relaxation of aorta and mechanisms in developing rats / 中国药理学通报

Aim To investigate the effect of chronic intermittent hypobaric hypoxia (CIHH) on relaxation of thoracic aorta rings in male developing rats and the underlying mechanisms. Methods Male neonatal Spra-gue-Dawlay ( SD) rats were randomly divided into eight groups respectively: CIHH treatment group (CIHH), group of one-week post-CIHH (CIHH-pl), group of two-week post-CIHH ( CIHH-p2 ) , group of three-week post-CIHH (CIHH-p3 ) , control group for CIHH (Con), control group for CIHH-pl (Con-1), control group for CIHH-p2 ( Con-2) and control group for CIHH-p3 (Con-3 ). Rats in CIHH groups were put into a hypobaric chamber with the mother rats 1 ~ 3 days before the birth to get a hypobaric hypoxia exposure mimicking 3 km altitude for 42 days, 5 hours daily. Rats in control groups were kept in the same environment as CIHH rats except hypoxia exposure. After anaesthetized with pentobarbital sodium (50 mg • kg-1 i. p. ), the thorax of rats was opened and thoracic aorta rings were made. The artery rings were placed in the bath chamber filled with K-H solution, and the relaxation of artery rings was recorded under normoxia or a-cute hypoxia conditions, respectively. Results (1) Under normoxia condition, the acetylcholine ( ACh)-induced relaxation of thoracic aorta increased obviously in CIHH groups compared with corresponding Con groups ( P < 0. 05 ). ( 2 ) The enhancing effect of CIHH treatment on thoracic aorta could be maintained for at least three weeks (P < 0. 05). (3 ) Under acute hypoxia condition, ACh-induced relaxation of thoracic aorta in each group decreased obviously, but the decrease in CIHH groups was significant less than that in Con groups ( P < 0.05 ). (4) The enhancement of CIHH on relaxation of thoracic aorta could be reversed by indomethacin (Indo), a cyclooxygenase inhibitor, glibenclamide (Gli), a KATP blocker, and Tempo, a free radical scavenger. Conclusions CIHH augments endothelium-dependent relaxation in thoracic aorta of developing rats. Also, CIHH can antagonize the inhibition of acute hypoxia on relaxation of thoracic aorta. The enhancing effect of CIHH treatment may be related with the increase of prostacyclin, the opening of KATP and free radical production.

Abordagem endovascular de lesão de aorta torácica penetrante - relato de caso / Endovascular treatment of penetrating thoracic aorta injury - case report

Resumo O cenário atual do trauma por causas violentas tem apresentado um elevado número de casos. Entre eles, a lesão de aorta torácica por trauma penetrante é uma condição de elevada morbimortalidade que exige diagnóstico adequado e que, nos últimos anos, tem sido corrigida com procedimentos endovasculares. Essa modalidade de tratamento se mostra mais segura, com menor número de complicações em relação ao procedimento cirúrgico aberto. Após a realização da abordagem endovascular, há necessidade de acompanhamento contínuo, que visa monitorar as condições de saúde do paciente e corrigir possíveis complicações relacionadas ao procedimento. O objetivo deste artigo é relatar um caso de traumatismo penetrante de aorta torácica, tratado por via endovascular, visto que a literatura aborda predominantemente as lesões por trauma contuso.

Abstract In the current scenario, traumas with violent causes are responsible for large numbers of cases. Among these, thoracic aorta injury caused by penetrating trauma is a cause of elevated morbidity and mortality, demanding adequate diagnosis, and can now often be repaired using endovascular procedures. This treatment method has proven to be safer, with a lower rate of complications than open surgical procedures. After endovascular repair, it is necessary to conduct continuous monitoring of the patient's health and correct any complications related to the procedure that may emerge. The objective of this article is to describe a case of penetrating trauma of the thoracic aorta that was treated endovascularly, since the literature predominantly covers blunt trauma injuries.